Ebook nhiễm khuẩn hệ thần kinh phần 2

Benh canh lam sang dien hinh la khdi phat cap tfnh, bieu hien la: liet, m at phan xa, giai doan soc tuy se het sau mot vai ngay hoac tuan, tien trien thanh liet m em vdi phan xa gan xUdn

VIEM TUY CAP

I D A I C lfO N G

1 Ljch sur

C) the ky thii XIX, hau het cac benh d tuy song deu diidc goi la viem tuy Morton Prince da viet trong Dercum’s Textbook of Nervous Disease nam 1895, de cap tdi viem tuy chan thiidng, viem tuy chen ep Cung vdi thdi gian, sii hieu biet ve cd che benh sinh cua benh than kinh da cd nhieu biidc tien bo, cac benh ly ve thudng ton tuy do cac nguyen nhan khac bi loai bo ra khdi bang phan loai nay va chi cdn lai thuat ngii viem tuy Nhiing cho den ngay nay sii lien quan giiia viem

va nhiem khuan cdn chiia ro rang Mot vai virut cham khac thiidng cd the pha huy cac te bao than kinh nhiing khong xuat hien cac te bao viem Ngay nay trong thiic te thuat ngii benh tuy (myelopathy) hay diidc dung hdn

2 Thuat ngCr

Tuy song la ndi cd the xay ra qua trinh viem, mot so" can nguyen tap trung pha huy cac neuron, so" khac tham gia qua trinh pha huy mang te" bao hoac chat trang va cd the gay hoai tii ca chat xam va chat trang Thuat ngut dUdc chap nhan hien tai cho tat ca cac benh ly tuy nay la benh ly tuy song (myelopathy) Ngoai ra cdn cd mot so" thuat ngii chuyen biet khac diidc sii dung de chi ra chi'nh xac hdn sii phan bo" cua qua trinh viem nhii sau:

- Neu thiidng ton gidi han d chat xam la viem tuy xam (poliomyelitis).

- Thiidng ton d chat tr&ng la viem tuy trang (leucomyelitis)

- Toan bo khu viic cat ngang cua tuy deu bi thudng ton diidc goi la viem tuy ngang (myelitis transversa)

- Neu thiidng ton d nhieu ndi va lan rong qua pham vi chieu dai la viem tuy rai rac (diffuse hoac disseminated myelitis)

- T huat ngii viem tuy - m ang tuy (m eningom yelitis) la dung trong trUdng hdp co sii phoi hdp cua viem m ang tuy va tuy song.

- Co the phoi hdp viem tuy song vdi viem day than kinh thi giac, goi la viem tuy thi than kinh (neuromyelitis optica)

- Cac dang benh ly viem tuy cap cdn cd the phoi hdp mot

so o viem dong thdi cd d tuy song va d trong nao, goi la viem nao - tuy cap tinh (encephalomyelitis acute)

Cd the phoi hdp viem tuy vdi viem re than kinh tuy song goi la viem re tuy song (myeloradiculiis)

- Mot dang viem tuy dac biet khac la viem tuy leo (liet leo Landry)

3 Khai niem ve the benh

- Viem tuy cap dUdc de cap khi cac trieu chiing benh xuat hien nhanh va dat giai doan toan phat trong vong vai ngay

- Ban cap la benh tien trien trong khoang thdi gian tii 2 den 6 tuan

- Viem tuy man tinh vdi thdi gian hdn 6 tuan ke tii khi khdi phat tdi khi phat trien day du benh canh lam sang

4 Nguyen nhan

Viem tuy cap bao gom nhiing thiidng ton cap ti'nh d tuy song, co the la tien phat hoac thii phat, do virut hoac vi khuan gay nen

- Nhiem khuan:

+ Tien phat: virut dai, poliovirut, Arbo virut

+ Thii phat: do virut bach hau, cum, sdi, vi khuan ly, phe cau, tu cau, lien cau, hoac do cac benh nhiem trung phiic tap khac nhii triic khuan giang mai, thiidng han, ly va cac loai nhiem khuan huyet khac gay nen

Nhilm doc: arsen, chi, thuy ngan va cac kim loai nangkhac

5 Dac diem thudng ton

Hinh anh thiidng ton benh ly theo qua trinh tien trien cua benh gom 3 giai doan:

5.1 Nhun tuy do

Giai doan b it dau cua viem, bieu hien sung huyet phu ne tuy, gian mach, xuat huyet nho, nhiing te bao than kinh bi thiidng ton tan nhan, tao khong bao, vd te bao Cac sdi true bi huy myelin Ve mat dieu tri chi co the lam tuy hoi phuc d giai doan nhun tuy do

5.2 Nhun tuy trdng

Cac te bao va to chiic than kinh bi hoai tii, te bao than kinh bi pha vd hang loat, sdi true bi pha huy

5.3 X o h o a

To chtic than kinh bi hoai tti diidc thay bang to chtic xd, xen ke cac te bao than kinh dem Day la sii seo hoa d vi tri to chtic tuy bi thiidng ton

II VIEM TUY NGANG CAP

Viem tuy ngang cap (VTNC) la the lam sang thudng gap nhat cua viem tuy cap Trong thiic te thiidng hay gap viem tuy ngang d doan tuy phinh that liing, doan tuy ngiic, rat it khi gap d doan tuy co

Nguyen nhan chu yeu tien phat do virut cung co the thii phat nhiing hiem (sau cum, sdi )

1 Lam sang

1.1 Hoi chitng nhiem khuan

Benh thudng khdi phat cap tinh bang hoi chting nhiem khuan Sot cao d cac mtic do khac nhau (tuy nhien cung co triidng hdp sot khong ro) kem theo dau cac day than kinh d khu viic bi viem, dau lan trong khoanh doan da do re than kinh cua cac khoanh tuy do chi phoi Sau mot vai ngav xuat hien trieu chting than kinh khu tru

1.2 Hoi chitng thitctng ton than kinh khu tru

Tuy theo khu viic tuy bi thiidng ton ma co nhting trieu chting tiidng ting, dau hieu lam sang phat trien dien hinh cua mot thiidng ton cat ngang tuy song

- Roi loan van dong: kieu diidng dan truyen, liet phan cd the du'cli mtic tuy thiidng ton, giai doan dau liet mem (dac diem quan trong), triidng liic cd phan chi liet giam, giai doan sau chuyen sang liet ciing

- Roi loan ve phan xa: phan xa gan xUdng m at (tiidng iing phan chi liet), phan xa da bung mat.

- Roi loan cam giac: mat cam giac kieu diidng dan truyen, mat toan bo cac loai cam giac diidi khoanh tuy thiidng ton, ngay tren vung thiidng ton mat cam giac la vung tang cam

- Roi loan cd vong: thiidng xuat hien sdm d da so’ benh nhan bieu hien la bf dai, dai kho, den khi liet nang chuyen sang dai dam

- Roi loan dinh dudng, thiic vat: benh nhan cd roi loan dinh diidng tram trong d khu vUc bi thiidng ton, bieu hien lam sang la loet diem ty sdm, loet rong, sau va rung long toe

Tat ca cac trieu chiing tren chiing to tinh chat cua mot liet mem la hau qua cua mot giai doan soc tuy nang ne

2 Xet nghiem

Dich nao tuy: nhieu triidng hdp khong thay doi dang

ke, mot so" cd bieu hien tang albumin, bach c iu N, L

- Mau: cd the tang to"c do mau lang, thay ddi cong thiic bach cau

Cay khuan: cay DNT hoac cay mau ft khi phan lap diidc vi khuan

Chan doan huyet thanh dac hieu cung ft triidng hdp xac dinh diidc ro loai virut gay benh

3 Chan doan

3.1 Chan doan xac djnh

Chan doan viem tuy ngang cap cd ban diia vao lam sang

Chan doan dinh khu can cti vao cac trieu chting than kinh (roi loan van dong, cam giac ).

3.2 Chan doan phan biet

3.2.1 Phan biet vdi roi loan tuan hoan tup:

Co trUdng hdp viem tuy cap khdi phat dot ngot bang liet hai chan, roi loan cam giac va roi loan cd vong kieu dot quy tuy song, vi vay can chan doan phan biet vdi tac dong mach tuy song Sif kien nay thifdng chi xay ra d khu vUc cua dong mach tuy song trUdc Dong mach nay cung cap mau cho 2/3 trifdc cua tuy, tif nuoi dudng chi b in g mot so' nhanh mach mau rat han che Trong khi dong mach tuy song sau difdc cung cap bdi so lifdng nhanh mach mau d nhieu mtic khac nhau Hoi chting dong mach tuy trUdc thifdng xay ra do tac mot trong nhting mach nuoi Benh thifdng xay ra d ngifdi huyet ap cao, vtia xd dong mach, chan thifdng, chup dong m ach

Benh canh lam sang dien hinh la khdi phat cap tfnh, bieu hien la: liet, m at phan xa, giai doan soc tuy se het sau mot vai ngay hoac tuan, tien trien thanh liet m em vdi phan xa gan xUdng nhay va phan xa da gan chan dao ngifdc Them vao do, roi loan cam giac phan ly (m at cam giac dau, nhiet do, nhUng cdn cam giac sau va cam giac tif the vi cot sau dufdc nuoi dudng bdi dong mach tuy song sau).

3.2 Phan biet vdi u tuy

Cd the viem tuy gia u, trieu chting than kinh tien trien nang dan len, nhUng trong u tuy tien trien cham hdn.

Dau la benh canh noi bat, d nhieu benh nhan benh khdi phat bat thifdng vdi cac trieu chting cua mot thifdng ton ngoai tuy nhif dau re, dau khu tru d lifng, hoac dau lan toa d mot chi

va vdi dac tfnh tang len khi ho hoac keo cang re

Roi loan van dong co the xay ra, liet ciing sdm, loet muon

va nhe hdn

- Co nghen tac lUu thong DNT, xet nghiem DNT co phan ly

albumin - te bao, chup tuy can quang thay vi tri tuy bi chen ep.

3.3.3 G iang m ai tuy' song:

- ThUdng ton: chu yeu gay thudng ton cot sau tuy song, (hay gap la thifdng ton bo Goll va cac re sau vung tuy that lifng- cung

- Trieu chiing lam sang: roi loan cam giac chu quan va khach quan; dau la trieu chiing dien hinh cua benh, tfnh chat cua dau rat dac biet: benh nhan dau d mot vung nhu kim nhon cham chfch, dau nhif dien giat hoac set danh, cdn dau xuat hien tii nhien hay do kich thich

- Roi loan cam giac khach quan chu yeu hai chi dudi, mat cam giac sau Benh nhan di bang mat, do do khi khong co anh sang benh nhan khong the di lai difdc

G iam trUdng liic cd va m at phan xa gan xUdng (do thudng ton re sau cua cung phan xa khoanh tuy).

Roi loan than kinh thiic vat

- Thay doi trong dich nao tuy: te bao tang, protein tang, chu yeu la globulin

3.2.4 X o nao - tup rai rac:

Thuoc benh thoai hoa myelin, thudng ton bieu hien rai rac

d nao, tuy song, d tieu nao, day than kinh thi giac Benh tien trien tiing ddt mot va rat hiem gap d Viet Nam

L am sang: bang lam sang rat da dang, thudng phoi hdp

m ay hoi chiing nhU: hoi chiing thap, hoi chiing tieu nao, roi loan cam giac, roi loan m at va tien dinh.

Dac biet can phan biet la cac triidng hdp thiidng ton benh

ly khu tru d tuy song Benh thiidng xuat hien d tuoi thanh va trung nien, dien bien co tfnh chat tuan tien Co the ca trong qua trinh benh chi co trieu chiing liet hai chi dudi

3.2.5 N goai ra cdn phan biet vdi:

Chan thiidng tuy song

- Cac benh ly cua cot song gay chen ep tuy

Nuoi diidng: chu y tang thanh phan dam

- Chong loet: dem lot diem ty, trd minh 1 - 2 gid mot lan, lau sach da

Chong nhiem trung dudng tiet nieu: khong dat sonde neu benh nhan dai dam, neu benh nhan bi dai thi cho dat sonde 2 -3 ngay rut ra, cho benh nhan tap di tieu tien, dan ltfu niidc tieu kin, vo trung Neu da nhiem khuan bang quang phai riia bang Rivanol l% o hoac dung dich thuoc tim 4%o

Tap van dong, cham ciiu, xoa bop, dieu tri ly lieu

5 Tien trien va tien lirdng

Neu dieu tri sdm, tich ciic, san soc ho ly tot thi benh nhan

cd the hoi phuc mot phan Da cd triidng hdp cd di chiing bai hoac liet hai chi diidi, roi loan cd vong hoi phuc tot, nhUng

cung co trUdng hdp khong hoi phuc dUdc NhUng benh nhan tu vong la do suy kiet va boi nhiem.

III VIEM TUY LEO CAP (HOI CHL/NG LANDRY)

Viem tuy leo cap (Landry) co dac diem lam sang khdi phat giong viem tuy ngang cap, nhUng tien trien nhanh chong hang ngay hang gid, lan dan tti thap len cao va co the thUdng ton len hanh nao, gay tti vong nhanh do suy thd, truy tim mach Tien lUdng de dat, ty le tti vong cao

1 Lam sang

Khdi phat thudng thudng ton d tuy lung, vdi bieu hien liet mem hai chi dudi, trong vong mot vai ngay liet len hai chi tren

Benh nhan trd thanh liet mem tti chi, cd the thay phan xa benh ly bo thap d hai chi dudi Mtic do mat cam giac cung lan dan tti chan len bung, ngUc, len chi tren va len cd Roi loan cd vong kieu trung Udng, ltic dau thudng la bi dai tieu tien, sau dai dam ng&t quang Ddi khi thudng ton hai ben tuy khong dong deu, ben nay nang hdn ben kia hoac sdm hdn ben kia, tao nen mot hoi chting kieu Brown - Sequard

Sau dd benh tiep tuc tien trien: benh nhan dau d co, gay roi liet cac cd d co, thUdng ton day than kinh hoanh, bieu hien kho thd; thudng ton nhan day than kinh IX, X, XII, bieu hien: noi kho, nghen, sac, mat phan xa hong - hau, liet van dong lUdi Cuoi cung roi loan nhip tim va benh nhan tti vong do truy tim mach

Mtic do liet va roi loan cam giac luc dau cang nang thi tien trien cang nhanh va tien lUdng cang xau, benh nhan cd the chet trong vai ngay.

N hiing trUdng hdp nhe, miic do thudng ton khong n&ng, dUdc ciiu chiia kip thdi, benh nhan khong tii vong thi sau

10 - 15 ngay bat dau trieu chiing hoi phuc mot phan, da so de lai di chiing, thUdng de lai di chiing bai hoac liet ciing hai chi dudi O chi tren co the phuc hoi tot hdn, co the con di chiing liet hai chi dudi kieu trung Udng ket hdp bai hai chi tren hoac mot chi tren kieu ngoai vi (do thudng ton d phinh co), bieu hien: liet m em , teo cd, m at phan xa gan xUdng, hiem gap liet ngoai vi d hai chi dudi (thudng ton phinh that lung).

Roi loan cd vong co the dUdc phuc hoi, benh nhan dai tieu tien chu dong dUdc.

Rat hiem trUdng hdp hoi phuc hoan toan khong de lai di chiing gi.

2 Dieu trj

Dieu tri viem tuy leo cap giong nhu dieu tri viem tuy ngang cap Dieu can chu y d day la phat hien sdm the benh nay, khi cd kho thd thi phai ho trd ho hap kip thdi, hoi siic tich ciic cho benh nhan

IV VIEM TUY THj THAN KINH (BENH DEVIC)

La mot the dac biet cua viem tuy ngang cap Bieu hien cua viem ket hdp day than kinh thi giac vdi viem tuy ngang The benh nay ve lam sang, phat trien va dieu tri tUdng tii nhu viem tuy ngang cap

Thudng ton dac hieu la thoai hoa bao myelin cua sdi than kinh, gap d day than kinh thi giac chu yeu d giao thoa thi giac Trong nhieu trUdng hdp day la giai doan dau cua bieu hien xd nao tuy rai rac

Thudng ton bat cii ndi nao cua tuy song, nhUng phd bien nhat la tuy song nguc

1 Lam sang

Khdi phat tUdng doi dot ngot, trieu chting giam thi liic va liet 2 chi diidi co the cung xuat hien, hoac trieu chting thi giac xuat hien trUdc chting vai ngay hay vai tuan

Roi loan thi giac dUdc bieu hien b&ng tu nhien giam thi liic

d mot hay ca hai ben, thiidng co am diem trung tam va thu hep thi trUdng, gai thi co hien tUdng phu viem , giam thi liic tti nhe tdi mu han vdi toe do tUdng ddi nhanh.

Sau 1 - 2 ngay hoac 1 tuan cd trieu chting cat ngang tuy song, cd trieu chting roi loan van dong va roi loan cam giac kieu dudng dan truyen, roi loan cd vong

Cd the cd trieu chting ve nao: dau dau, roi loan y thiic nhe,

cd the cd co giat kieu dong kinh, cd khi la dong kinh tuy song (co cting 2 chi dudi, dau ddn)

2 Xet nghiem

Xet nghiem DNT: da so' la trong gidi han binh thudng, so it

cd tang albumin nhe

3 Tien trien

Ket qua dieu tri tUdng doi kha quan sii phuc hoi trUdc tien

la day than kinh thi giac dudi tac dung cua corticoid Mot so de lai di chting giam thi liic, teo gai thi

V VIEM TUY XAM CAP (BENH BAI LIET)

Con ngUdi da biet benh viem tuy xam tti hang the ky nay Nam 1840 Jacob Heine da mo ta benh canh lam sang dau tien Nam 1890 Medin da bo sung nhting hieu biet ve dich te hoc cua benh Dau the ky 20 Landsteiner, Popper, Flexner, Levis

da xac dinh dUdc benh do virut gay ra Ngay nay ngUdi ta da biet v i r u t gay benh bai liet la Poliovirut

Dac diem cua virut bai liet: co ai ti'nh cao vdi te bao

th in kinh van dong (nhat la nhiing te bao than kinh van dong ldn), pha huy te bao than kinh d siing trUdc tuy song va than nao, phan huy chat nhiem sac va ton tai trong te bao difdi dang bao quan lia acid va gay hoai tii te bao, chiing co the keo theo viem mang tuy vung ke can virut bai liet con co the xam lan tan cong te bao sOfng sau tuy song, cac te bao hach than kinh va cac to chiic than kinh trung lidng (nhiing rat hiem)

Diidng xam nhap: virut bai liet xam nhap vao cd the qua diidng mieng, chung sinh san d hong, ruot va to chiic lympho bao cua amidan, sau do vao hach co va mac treo ruot roi vao mau (thdi gian chung d trong mau rat ngan), vao giai doan nay chiing khong gay trieu chiing lam sang Sau do chung xam nhap vao to chiic than kinh bang con dudng nao thi y kien cua cac tac gia con chua thong nhat Da so cac tac gia cho rang co hai con dudng xam nhap la qua hang rao mach mau - nao va qua synap than kinh - cd

chien ludc cua To chtic Y te the gidi la tien tdi thanh toan benh nay tren toan the gidi.

2 Lam sang

Benh khdi dau giong nhiem khuan cap, 25% trUdng hdp cac trieu chting khdi phat mat di sau 36 - 48 gid, sau dd benh nhan thay stic khoe hoi phuc 2 - 3 ngay Tiep theo la sot ddt 2, kem theo hoi chting mang nao: dau dau tang dan, dau cd xuat hien va thudng khu tru d gay va that lung, cd the cd roi loan y thtic nhe ThUdng sau khi cd trieu chting than kinh dau tien khoang 3-5 ngay thi liet xuat hien NhUng cung cd khi liet la trieu chting than kinh xuat hien dau tien hoac rat muon (sau2-3 tuan) ThUdng ton van dong tien trien nhanh trong vong3-5 ngay Liet thudng khu tru d tti chi, cung cd khi cd than cung thudng ton Nhting trUdng hdp nang cac cd ho hap va cd hoanh cung bi liet Thong thudng trieu chting sot ton tai 4 - 7 ngay, sau dd than nhiet giam dan va trd ve binh thudng

3 Xet nghiem

3.1 Dich nao tuy

Trong dich nao tuy thudng thay tang te bao, tti 10 - 200 bach cau/mm3, hiem khi tdi tren 500 bach cau/mm3 O giai doan sdm cua benh, ty le bach cau da nhan so vdi lymphocyt thudng cao nhUng chi trong vai ngay ty le dd se dao ngUdc Protein nao tuy tang vtia, trung binh khoang 40 - 50mg/100mm3 nhUng cung cd trUdng hdp mtic protein tang cao hdn ntia va ton tai trong nhieu tuan Cdn lUdng glucose nao tuy trong ranh gidi binh thudng

5.3.2 Phan lap virut:

Lay phan cua benh nhan ngay khi mdi khdi phat va trong cac thdi gian tiep theo NgUdi ta thudng sti dung nuoi te bao cua ngUdi hoac cua khi de theo ddi sU phat trien cua virut bai

liet Co the phat hien dUdc virut bai liet d benh nhan trong vong 2 tuan dau vdi ty le 80% nhUng sang 2 tuan tiep do chi dat dUdc ty le 20%.

5.3.3 H uyet thanh hoc:

Cac khang the trung hoa thifdng xuat hien sdm va co the phat hien dUdc ngay sau khi benh nhan vao vien Can lay mau kep de thif phan ting huyet thanh va qua dd danh gia dUdc hieu gia khang the

4 Chan doan

6 da so" cac trifdng hdp chan doan cd the de dang, can ci( vao liet mem tien trien khong doi xting, thay ddi dich nao tuy Trong nhting trUdng hdp khong dien hinh hoac mdi d giai doan khdi phat, neu benh nhan mdi dUdc tiem chung hoac d vung dang cd dich can sdm nghi tdi viem tuy xam

Dich nao tuy thay cd tang ap luc, tang te bao, tang dam nhe (neu liet nang cd the tang 1 - 3g/l) LUu y te bao tang sdm

(trUdc khi liet) va giam nhanh, trong khi dd dam tang muon va ton tai nhieu tuan sau

5 Dieu trj

Dieu tri viem tuy xam nhu dieu tri viem tuy ngang

Hien nay chua cd phUdng phap dieu tri dac hieu nen can phai dieu tri trieu chting Van de quan trong la trong giai doan cap, ngay tai giUdng benh da phai de phdng cac bien dang tu the O cac giai doan sau can day manh phuc hoi chtic nang

6 Tien lUdng

Gan 10% tti vong trong giai doan dau cua benh do suy thd, suy ho hap va bien chting phoi

The co thiidng ton hanh nao co ty le tti vong cao nhat (tren50%).

Tien liidng xau neu co liet rong, liet tien trien cham va co cac ddt gay liet them cac nhom cd mdi

Sii phuc hoi phu thuoc vao mtic do lan rong va mtic do nang ne cua liet

Mot so" benh nhan co hoi chting Postpolio bieu hien bang cac trieu chting: yeu cd tai phat, teo cd tien trien va rung giat

bo sdi cd Hay con goi la teo cd tien trien sau viem tuy xam

7 Phdng benh

Can sti dung vicx in phong bai liet cho tat ca cac tre em va trong cac vu dich Co hai loai vacxin hien nay: loai vacxin bat hoat vdi formalin va loai vacxin Sabin Niidc ta thiidng xuyen thiic hien chiidng trinh tiem chung md rong phdng 6 benh pho bien, trong dd cd benh bai liet tre em

VI VIEM NAO - TUY DO TIEM VACXIN PHONG BENH DAI

Khi tiem vacxin phdng benh dai cd the gay nen viem nao - tuy Trieu chting thiidng xuat hien sau khi tiem lan cuoi ciing

va cd the sau khi tiem vacxin khoang 1 - 2 thang

Cd 3 the lam sang chinh:

Liet leo cap tinh: benh canh giong nhii benh tuy leo cap ti'nh neu d tren Benh nhan sot, dau dau, tang ki'ch thich, sau

2 - 3 ngay xuat hien liet 2 chi diidi, sau dd liet len hai chi tren

va liet len hanh nao, de doa ti'nh mang cua benh nhan

- The viem tuy that liing: benh canh lam sang giong nhut viem tuy ngang cap

- The viem nhieu day than kinh: bieu hien hay gap la thiidng ton cac day than kinh so nao nhii day VII, III, IV, V

va cac day than kinh nhii day tru, day quay, day than kinh hong to

Thiidng kem theo cac trieu chiing nao chung nhii nhiic dau, chong mat, buon non, non, co giat,v.v

VII MOT SO THE VIEM TUY CAP KHAC

1 Viem tuy cap mot phan

Thiidng ton khong c&t ngang hoan toan tuy song, do vay trieu chiing lam sang bieu hien khong mat dan truyen cua tuy song mot cach toan bo

Neu thiidng ton ngang 1/2 tuy song se gay hoi chiing Brown - Sequard Benh nhan mat toan bo cam giac sau va tinh

vi ben thiidng ton va kem theo liet mia ngUdi Ben doi dien thi mat cam giac nhiet, dau

ThUdng ton d mep xam triidc d vung phinh co se co bieu hien phan ly cam giac, mat cam giac dau va cam giac nong, lanh; con xuc giac va cam giac sau, khu tru d hai tay va nUa tren ngiic hinh canh biidm

2 Viem simg trudc tuy cap tinh

Virut xam nhap chu yeu vao dau siing triidc tuy song lam huy hoai cac te bao van dong cua siing triidc

Viem siing triidc tuy song cap tinh do virut bai liet: benh bai liet d tre em la mot the benh dien hinh Ngoai ra viem tuy

do virut khac gay nen ca d ngiidi ldn Bieu hien lam sang than kinh giong nhii benh bai liet, yeu liet kieu ngoai bien, liet mem, triidng liic cd giam va dinh diidng roi loan nhanh vdi phan iing thoai hoa dien

Tom lai viem tuy cap (hay co the goi la benh tuy cap tinh)

do nhieu nguyen nhan gay nen, co nhiing the lam sang khac nhau, can chu y kham ky ve than kinh de chain doan dinh khu

va chan doan xac dinh benh Viec dieu tri can chu y khau san soc ho ly, phuc vu benh nhan

BENH BAI LIET

I DAI CLTONG

1 Djnh nghTa

Bai liet la benh truyen nhiem cap ti'nh do virut bai liet gay

ra, benh lay theo diidng ho hap va dudng tieu hoa Dac diem lam sang chu yeu la nhiing bieu hien liet mem ngoai vi, khong

co roi loan cam giac kem theo

Benh do Heine mo ta lan dau tien vao nam 1840, sau do la Medin (1887) nen con diidc goi la benh Heine - Medin

Typ I: dien hinh la chung Brunhilde

Typ II: dien hinh la chung Lansing

Typ HI: dien hinh la chung Leon

Trong do typ I chu yeu gay benh cho ngUdi d the dien hinh,

typ II gay benh the an va typ III it gay benh hdn

Virut co tinh chiu diing cao vdi ngoai canh: trong phan ngifdi chiing song diidc vai ngay den vai tuan, trong niidc co the tdi 14 ngay De bi diet bang cac thuoc khu trung thong thUdng nhU: chloramin B, nUdc oxy gia, thuoc tfm va tia ciic tim 6 60°C, virut bi diet trong 30 phut

3 Nguon benh

La nhiing benh nhan bi benh bai liet Virut cd d hong va d phan ngUdi benh trUdc va sau khi khdi phat cd the den 2 tuan hoac hdn.

Ngoai ra, ngUdi mang virut khong cd trieu chiing lam sang (ngUdi lanh mang virut) cung la mot nguon lay quan trong

4 Dudng lay

Bang viec phan lap dUdc virut d hong, ngUdi ta da xac dinh dUdc virut bai liet lay theo dudng ho hap trong thdi ky diu cua benh

NhUng benh lay chu yeu b in g dudng tieu hoa, thong qua tay va dung cu nhiem ban, vdi vat chu trung gian truyen benh

la ruoi Virut dUdc thai ra theo phan cua ngUdi benh trong thdi gian dai (tdi vai thang) va xam nhap vao dudng tieu hoa (mieng) cua ngUdi lanh

5 Sure cam thu va mien djch

NgUdi cd siic thu benh cao vdi virut bai liet Tuoi hay gap

la tre em tii 2 - 8 tuoi, dac biet la tre 2 - 4 tuoi chiem tdi

60 - 80%, tre sd sinh va ngUdi ldn cd the bi nhUng ft hdn va thudng la khong dien hinh

Sau khi bi benh bai liet benh nhan thifdng co mien dich ben vflng, hiem khi mac lai.

6 Tinh chat djch

Benh thifdng tan phat, doi khi thanh dich d nhiing tap the nho nhu nha tre, trUdng mau giao, trUdng pho thong cd sd, d thanh pho nhieu hdn nong thon va hay xay ra vao cuoi mua xuan, dau mua he hang nam

Nhd co vacxin Sabin, nhieu nUctc tren the gidi da day lui va thanh toan tan goc benh bai liet C) Viet Nam, benh dUdc xep vao mot trong cac benh nam trong chUdng trinh tiem chung

md rong cho tre em va nUdc ta da tuyen bo" thanh toan benh bai liet vao nam 2000

II CO CHE BENH SINH VA GIAI PHAU BENH LY

1 Cd che benh sinh

Tii khi xam nhap vao cd the den khi vao he than kinh trung Udng gay benh canh lam sang dien hinh (liet), virut bai liet phai hai lan vao mau va khu tru d mot so phu tang Qua trinh dien bien qua 3 giai doan:

- Giai doan xam nhap va tang sinh d dUdng tieu hoa: virut vao cd the qua hau, hong, trong 24 gid dau da den cac hach bach huyet quanh hong, vao niem mac tieu trang va tang sinh d do (co the phan lap dUdc virut d nhay hong va phan trong giai doan nay)

Giai doan noi tang: tif niem mac dUdng tieu hoa, virut vao mau (lan 1) sau do den cac noi tang (tim, gan, tuy, thudng than, ho hap ) Tai day chung tiep tuc tang sinh va gay ra cac bieu hien lam sang cua thdi ky tien liet

- Giai doan xam nhap va tang sinh cl than kinh trung Udng: virut tti cac noi tang vao mau (lan 2) va vao he than kinh trung ifdng, chu yeu la cac neuron van dong d sting triidc tuy song.

Ddi vdi the khong dien hinh (khong cd liet), virut chi xam nhap tdi cac hach bach huyet, niem mac difdng tieu hoa hoac tdi mau ma khong vao he th in kinh trung ifdng, sau dd bi dao thai ra ngoai theo phan

2 Giai phau benh ly

Thifdng ton chu yeu la d sting trifdc tuy song, ngoai ra la d sting ben, sting sau cung cd the bi viem nhUng thifdng la thifdng ton nhe va khong dien hinh Doan tuy co va that lung

la nhting ndi thudng ton hay gap nhat, tiep theo la vung than nao, cac nhan van dong, tien dinh, he ludi, tieu nao va cac day than kinh so nao

- Ve dai the: mang nao - tuy phu ne sung huyet, chat xam d sting trUdc tuy song cd mau hong hoac mau vang xam, chat trang sung huyet va cd nhting dam xuat huyet rai rac

- Ve vi the: thifdng ton sdm nhat d te bao than kinh la hien tUdng tieu huy the Nissl trong nguyen sinh chat, dan tdi tinh trang cac neuron bi thoai hoa va phan ting viem quanh cac neuron, cac mach mau va to chtic dem, dong thdi cd hien tiidng xam lan cac bach cau da nhan, lympho bao, dai thiic bao Hau qua cua sii thoai hoa cac neuron, phan ting viem va sii xam lan te bao lam teo sting trifdc tuy song, xd hoa to chiic dem va thanh mach Tuy nhien, da so" cac thiidng ton diidc phuc hoi va cac chtic nang than kinh cung cd the dUdc phuc hoi sau 1 - 2 thang Mot so" neuron bi thifdng ton nang khong hoi phuc (tren lam sang the hien b in g cac di chting)

Cac cd quan ngoai he than kinh cung co the bi virut tan cong nhu ho hap, tim , gan, than, tieu hoa v.v nhUng cac thUdng ton thUdng nhe va nhanh hoi phuc.

III LAM SANG

1 The thong thudng dien hinh (hay the liet - Paralytic

poliomyelitis)

The nay chiem 1% trong so cac the benh

1.1 Thdi ky nung benh

Khoang 5 - 35 ngay, trung binh 6 - 20 ngay

1.2 Thdi ky khdi phat (hay giai doan tien liet)

Tu: 3 - 7 ngay vdi nhieu bieu hien phong phu:

Sot: khdi phat dot ngot, da so" sot nhe, mot so trUdng hdp sot cao 39 - 40°C, keo dai trong 3 - 4 ngay

- Viem long dUdng ho hap tren: ho khan, hat hdi, chay nUdc m i t nUdc mui, giong noi khan.

- Roi loan tieu hoa: non, buon non, di ngoai phan tao hoac long

Roi loan than kinh thiic vat: tre va nhieu mo hoi, net mat luc tai luc hong, mach cham (ngUdc lai vdi mach nhanh khi sot cao).

- Trang thai tam than kinh: ly bi hoac vat va, hay keu khoc

- Dau va co ciing cac cd la dau hieu rat sdm va pho bien Day la nhUng dau hieu rat cd gia tri de chan doan sdm vi nhiing cd nao dau se phat trien liet, thudng dau va co ciing cac

cd vung co, than minh va sau dui lam tre met moi, siic cd yeu, trUdng luc cd giam, doi khi co hien tUdng co giat nhe d nhiing

cd sau nay se bi liet Kem theo co bieu hien giam hoac mat phan xa (khi mat phan xa da bung tdi 80% co liet chi dudi)

Hoi chiing mang nao: nhiic dau nhieu (kem theo non, buon non) Kham cac dau hieu thiic the: ciing gay (+), Kernig (+), Brudzinski (+) d tre nho dUdi 18 thang co the thay thop phong hoac dau hieu Hoyne (+): de tre nam ngiia, dung 2 tay thay thuoc nang nhe 2 vai tre, dau tre khong ngoc len dUdc theo

Xet nghiem dich nao tuy co the thay te bao tang nhe, protein binh thUdng hoac tang it, glucose va NaCl binh thudng

1.3 T h d i k y to a n p h a t (hay giai doan liet)

Dac diem cua liet:

+ Liet nheo ngoai vi, khong doi xOfng

+ Liet khong theo mot thii tii nhat dinh

+ Liet xay ra dot ngot va nhanh, thudng xuat hien vao ngay thii 4 - 7 cua benh, khi nhiet do da ve binh thudng hoac het sot trUdc do 1 - 2 ngay Tit khi bat dau co liet den khi liet khong tien trien mia chi trong vong 48 - 72 gid

+ Cac cd bi liet thudng yeu, trUdng liic cd giam, mat hoac giam phan xa gan xUdng va phan xa da, cd teo nhanh Diem dang chu y la d cac cd nay khong co nhiing roi loan cam giac kem theo

Dinh khu cua liet: tuy theo vi tri thUdng ton co cac thesau:

+ The tuy song: chiem 60 - 70% the co liet

Thiidng ton tuy co: liet cd co, vai, gay, chi tren (cd vai)

Roi loan ho hap: nac nhieu, kho thd, roi loan nhip thd.Roi loan tuan hoan: mach khong deu hoac truy mach, roi loan nhip tim, huyet ap dao dong va cd xu hiidng giam.Roi loan than kinh thiic vat: sot cao, va nhieu mo hoi,

da tim tai

Day la the rat nang, tii vong cao (50 - 90%)

+ The tuy song - hanh tuy: la thudng ton phoi hdp 2 the tren, chiem 15 - 25% cac the cd liet

+ The nao: cd the ddn thuan hoac phoi hdp vdi thudng ton hanh tuy - tuy song Neu la the nao lan toa ddn thuan thudng rat kho phan biet vdi viem nao do cac loai virut khac Day la the hiem gap, tien trien keo dai va de lai nhieu di chiing

Cac trieu chiing khac:

+ Dau hieu dau cd: tang len khi bat dau liet, keo dai vai ngay sau dd giam dan, kem theo dd dau dau, tinh tao hdn, an ngu kha hdn, dd met mdi

Cong thiic te bao: luc dau chu yeu la bach cau da nhan trung tinh, sau vai ngay bach cau lympho chiem tfu the dan va trd ve binh thiidng tvf tuan thii 4 cua benh Protein trong dich nao tuy co the tdi 1 - 2 g/1, cao nhat vao tuan thii 3 va trd ve binh thiidng sau 1 - 2 thang Khoang 10% so triidng hdp co dich nao tuy binh thiidng Tuy nhien, te bao tang va protein tang khong lien quan den miic do benh.

Phan lap virut: tii mau (triidc khdi phat 2 - 3 ngay va sau khdi phat 1 - 2 ngay), tii nhay hong (triidc khdi phat va keo dai 10 ngay sau khdi phat), tii phan (triidc khdi phat va keo dai tdi khi hoi phuc)

Huyet thanh chan doan: phan iing ket hdp bo the va phan iing trung hoa

1.4 Thdi ky hoi phuc va di chung

Hoi phuc sdm: trong 6 tuan dau cua benh, cac cd bi liet phuc hoi nhanh, giam va het dau, chi de lai mot so" it cd va nhom cd bi liet hoan toan Dd la do da so cac neuron than kinh chi phoi cac cd liet luc dau chi bi phu ne va roi loan chiic nang, sau dd hoi phuc

Hoi phuc muon: sau 6 tuan tdi 2 - 3 nam, cd cd bi liet giam cham va khong ro rang, nhieu cd bi liet hoan toan

- Di chiing: la nhiing thiidng ton khong hoi phuc sau 3 nam

2 Mot so the lam sang khac

2.1 The khong trieu chung lam sang

The nay chiem tdi 80 - 85% cac the benh Chan doan xac dinh diia vao viec phan lap virut tu! phan benh nhan va sii cd mat cua khang the trong huyet thanh

2.2 The nhe (abortive poliomyelitis)

Chiem 4 - 8%, bieu hien bang trieu chiing viem long dudng

ho hap tren, roi loan tieu hoa va mot so' trieu chiing giong cum (sot, dau khdp) Chan doan cung phai dUa vao phan lap virut

va phan iing huyet thanh

2.3 The khong liet (non paralytic poliomyelitis)

Chiem 10%, benh nhan co cac trieu chiing: cua thdi ky tien liet (d the liet), noi bat la hoi chiing mang nao va cac dau hieu kich thich mang nao nhiing khong cd liet

IV CHAN DOAN

1 Chan doan xac djnh dira vao

Lam sang: sot cao, dau cd

Liet nheo ngoai vi khong doi xiing: xay ra dot ngot, giam phan xa gan xiidng va khong cd roi loan cam giac kem theo

- Xet nghiem: phan lap virut tii mau, nhay hong, phan theo tiing thdi ky benh Phan iing trung hoa hoac phan dng ket hdp bo the vdi hieu gia khang the lan hai tang cao hdn lan thii nhat

Dich te: tuoi de mac benh (2 - 8 tuoi) va cd nhieu tre trong mot tap the ciing bi tUdng tu.

2 Chan doan phan biet

2.1 Thai ky tien liet

- Benh cum va nhiem virut diidng ho hap do virut khac: sot cao lien tuc tdi 4 - 7 ngay, thiidng cd ret, nhiem doc nang hdn, dau dau dii doi, benh dien bien nhanh trong vong 7 - 1 0 ngav

- Viem mang nao mu: hoi chiing mang nao xuat hien sdm va ram ro hdn, dich nao tuy due, te bao tang rat cao chu yeu la bach cau da nhan trung tinh, protein cao, glucose giam Bach cau mau ngoai vi tang, chu yeu la bach cau da nhan.

- Viem mang nao do virut khac: chu yeu diia vao tien trien nhanh cua benh sau 1 - 2 tuan

2.2 Thdi ky liet

Can phan biet vdi hoi chiing viem da re - day than kinh (Gullain - Barre): hay gap d ngiidi ldn, liet cd tfnh chat doi xiing d dau chi, benh it de lai di chiing

V DIEU TR| VA D I/ PHONG

1 Dieu trj bai liet the Met

1.1 Nguyen tac dieu trj

Dieu tri toan dien, ket hdp chat che dieu tri trieu chiing (chong viem, giam dau, hoi siic ho hap, tuan hoan ) vdi viec nang cao siic de khang cua cd the

- Tich ciic de phdng bien chiing va di chiing, tao moi dieu kien de benh nhan phuc hoi chiic nang va tam ly

1.2 Giai doan tien liet

Bat dong benh nhan trong 1 - 2 tuan

- Neu cd sot cao phai ha nhiet, de phdng co giat bang cach chiidm lanh hoac dung thuoc (paracetamol, Efferalgan, aspegic)

Giam dau, an than: analgin, aspirin, Dimedrol (tiem bap hoac uong), Seduxen

Neu co phu nao: glucose 30 % tiem, truyen tinh mach ket hdp m agie sulfat, ldi tieu.

- Tiem b ip thit calci gluconat trong 7 - 10 ngay

1.3 Giai doan liet

- Dat benh nhan d tif the phong di dang

Tich ciic hoi siic tuan hoan, ho hap neu do thiidng ton nang d the hanh tuy: dat nam nghieng theo tii the dan liiu, hut ddm dai, thd oxy, ho hap nhan tao, boi phu niidc - dien giai, trd tim mach (spartein, coramin), nang huyet ap (dopamin ), chong phu nao

- Thuoc phuc hoi van dong d cac cd bi liet:

Proseryl tiem bap dung dich 0,05% x 0,1-0,2 ml/ngay trong 10 - 15 ngay

Dibazol 1 - 5 mg/ngay uong lien tuc 20 ngay, ket hdp vdi vitamin nhom B

Khang sinh boi nhiem diidng ho hap va tiet nieu

Gamma globulin trong 7 - 10 ngay dau

- Ly lieu phap sdm (tii tuan thii hai cua benh) ngay sau khi het sot vai ngay, khong nen de den khi het dau vi nhiing benh nhan dau nhieu thiidng teo cd nhanh

Cd the ap dung cac bien phap: bo paraphin, dien phan, xung dien tan so cao chia lam nhieu ddt, mdi ddt 10-15 ngay, keo dai trong 1 - 2 nam

Ket hdp the due lieu phap (xoa bop, van dong tai cho ) vdi tam ly lieu phap

1.4 Giai doan hoi phuc va di chitng

- Tich ciic nang cao siic de khang cua cd the

- Tiep tuc cac bien phap ly lieu va the due lieu phap Cho benh nhan tap the due nhe nhang, tap di lai va cac cii dong khac.

Neu co di chiing co the dung phau thuat chinh hinh de can thiep

2 Dieu trj bai liet the nhe

Giam dau, an than, ha nhiet

Dieu tri cac roi loan tieu hoa

- T ang cUdng dinh diidng, nang cao siic de khang.

- Theo doi sat de phat hien tinh trang liet

3 Dieu trj bai liet the khong Met

Chu yeu la an th in , giam dau, chong phu ne nao

- Co the ap dung ly lieu phap (neu co bieu hien co that keo dai d cac bap cd) va theo doi trong vong hai thang

- Nhiing tre tiep xuc va ngUdi lam nhiem vu cham soc benh nhi phai dUdc theo doi sat Neu co trieu chiing nghi ngd: dau hieu mang nao, dau doc song lUng va co, giam trUdng liic d mot so" cd v.v phai xet nghiem dich nao tuy va cach ly

Can nhac viec c&t amidan hoac nao VA cho tre d vungdich.

Doi vdi nhiing benh nhan the nhe hoac the khong co liet can han che van dong, tranh kich thich dau cho den khi het trieu chiing lam sang

4.2 Dung vacxin

- Vacxin bat hoat Salk la loai vicxin diidc che tao tii chung virut bai liet bi bat hoai b ln g formalin Loai nay dung diidng tiem, do do chi tao diidc khang the ma khong gay diidc mien dich tai ruot Hien nay vacxin Salk chi diidc sii dung khi vacxin diidng uong khong co ket qua

- V icx in song giam doc liic Sabin co nhieu liu diem hdn: dung diidng uong, gay diidc mien dich lau ben, chong lai diidc sii xam nhap cua virut hoang dai (do tao diidc mien dich tai ruot), dat hieu qua 90 - 100%, gia thanh re

Tat ca tre em (nhat la tre tii sd sinh den 60 thang) diidc uong 2 giot vicx in Sabin 1 lan va hang nam uong lai Nhd co vacxin nay ma nhieu niidc da day lui va thanh toan diidc benh bai liet

GIANG MAI THAN KINH

Sau nhidm khuan giang mai ban dau, mot sd" triidng hdp cd the tien trien thanh giang mai than kinh 6 Hoa Ky, ty le benh nhan phai vao vien vi giang mai than kinh nam 1964 la 4,3/100.000 ngiidi dan (theo R D ADAMS va M VICTOR, 1985), thdi gian gan day ty le dd da giam di nhieu Cdn d niidc

ta chiia cd so lieu rieng ve giang mai than kinh nhiing trong

vong 10 nam tit 1982 den 1991 da phat hien diidc 92.587 benh nhan mac giang mai (Vien Da lieu, 1992) Mot ty le nhat djnh trong so benh nhan do sdm muon se co bieu hien cua giang mai than kinh.

I DAI C lfO N G VE GIANG MAI THAN KINH

1 Nguyen nhan

Nguyen nhan gay benh giang mai la xoan khuan Treponema pallidum Xoan khuan giang mai thiidng xam nhap vao he than kinh trung lidng trong vong tii 3 den 18 thang sau khi cd the bi nhiem benh Neu vao cuoi nam thil hai, he than kinh chua bi xam pham (qua chiing minh bang phan ilng am tinh trong dich nao - tuy (DNT)) thi 1/20 so benh nhan van tien trien thanh giang mai than kinh; neu vao cuoi nam thil 5 phan ilng van am tinh trong DNT thi ty le do se la 1/100

2 Lam sang

2.1 Viem mang nao

La bieu hien dau tien cua nhiem giang mai than kinh, co the xay ra theo ty le 25% doi vdi moi triidng hdp mac giang mai The viem mang nao nay kin dao va chi phat hien diidc qua xet nghiem DNT Han hifu benh canh co the nang hdn vdi bieu hien liet day than kinh so, dong kinh, cdn dot quy (do ket hdp vdi thudng ton mach mau) hoac cac trieu chiing cua ap liic qua cao trong so Loai viem mang nao nay cd khi keo dai am tham nhieu nam va sau cung gay thiidng ton nhu mo nao; tuy nhien mot so triidng hdp cung cd the khdi him

2.2 Dien bien lam sang

Moi the giang mai than kinh deu khdi dau vdi benh canh viem mang nao va deu kem theo it nhieu bieu hien viem d

mang nao Cac hoi chiing lam sang sdm la viem mang nao va giang mai mach mau nao; cac hoi chiing muon la giang mai mach mau xay ra sau 1 den 12 nam, roi den liet toan the, benh tabet, teo than kinh thi giac va viem mang nao - tuy Bon the benh sau cung la nhiing dien bien lam sang cua viem mang nao giang mai man tinh Hien nay, ngiidi ta van chiia biet ro cac giai doan benh ly trung gian bien chuyen tii viem mang nao giang mai kin dao (khong co trieu chiing lam sang) sang cac the giang mai th in kinh co thiidng ton nhu mo than kinh Cac thiidng ton giai phau triidc kia tiidng la dac biet cua giang mai than kinh thiic ra chi la nhiing phan ling man tinh cua mang nao: vi du viem va tac cac dong mach diidi nhen, viem mang nao - nao, viem mang ong noi tuy, viem mang nao - tuy, hay thay trong thiidng ton do giang mai than kinh deu cd the gap trong cac the man tinh cua viem mang nao.

2.3 The quan trong nhat cua giang mai than kinh

Giang mai than kinh khong cd trieu chiing bieu hien la the quan trong nhat cua giang mai than kinh Neu phat hien diidc

va dieu tri dung d in the nay ch ic chan se ngan ngiia diidc cac the giang mai than kinh khac Ngiidc lai, neu khong dieu tri hoac khong diidc dieu tri dung, mot so" benh nhan mac the nay chac chan se bi giang mai mach mau mang nao, liet toan the, tabet, v.v Thong thiidng giang mai mach mau hay gap la mach mau mang nao Trong moi the viem mang nao do vi khuan, nam hoac xoan khuan, d thanh cac dong mach diidi nhen hay thay cd mot phan iing viem Sang giai doan man tinh cua viem mang nao, thanh huyet quan se xd day len lam hep long mach va gay t ic mach

Trong thiic te cac benh canh giang mai than kinh it khi the hien diidi dang ddn thuan; ngtfdi ta hay thay cd sii ket hdp cac hoi chiing vdi nhau (vi du viem mang nao va giang mai mach mau, tabet va liet toan the v.v ) Vi vay khi kiem tra

giai phau co the phat hien diidc cac thudng ton lan toa ca d nao lan tuy song.

3 Djch nao - tuy (DNT)

La mot chi so kha nhay ddi vdi giang mai than kinh trong thdi ky hoat hoa, phan anh diidc tinh trang viem nhiem cua mang nao Tang te bao va protein trong DNT chiing to cd te bao viem xam nhap vao ldp mang nuoi va mang nhen; tuy vay cung cd triidng hdp chi thay protein tang ma thdi Ddi vdi giang mai than kinh, DNT tang tii 200 den 300 te bao trong

lm l, phan ldn la cac te bao lympho va te bao mot nhan; protein tang tii 40 den 200mg trong 100ml; liidng gamaglobulin cung tang va cac phan iing huyet thanh diidng tinh; cdn liidng diidng binh thiidng

Cac phan iing thong dung de chan doan giang mai nhii test Kolmer vdi ky thuat ket hdp bo the, test VDRL (Venereal Disease Research Laboratory) vdi ky thuat len bong, neu diidng tinh doi vdi xet nghiem DNT cho phep xac dinh cd giang mai than kinh Trong triidng hdp cac phan iing dd am tinh hoac diidng tinh gia se can phai tien hanh cac xet nghiem dac hieu nhii ky thuat hap thu huynh quang khang the xoan khuan FTA - ABS (Fluorescent Treponemal Antibody Absorption) hoac bat dong xoan khuan giang mai TPI (Treponema Pallidum Immobilization)

Du sao van can chu y tdi nhiing bien doi sdm nhat trong DNT la hien tiidng tang te bao va protein vi cd the da xuat hien vai tuan sau nhiem khuan va triidc khi cac phan iing huyet thanh trd nen diidng tinh Cang ve sau, dien bien cua DNT cd the thay ddi, vi du sau dieu tri hoac liic benh dd, liidng

te bao se trd ve miic binh thiidng roi tdi protein va ca gamaglobulin cung se giam, sau cung cac phan iing huvet thanh cung cd the trd nen am tinh Nhiing thong thiidng phan

ilng huyet thanh trong DNT se con diidng tinh lau mac dau da qua nhieu ddt dieu tri Neu DNT khong binh thildng thi phan ilng huyet thanh trong mau se diidng tfnh, nhiing cung co triidng hdp lai thay phan ilng trong mau am tinh.

Trong chan doan, dieu tri va tien liidng benh giang mai than kinh thi DNT gid mot vai tro hiidng dan it sai lam, co the noi con quan trong hdn ca trieu chiing lam sang O mot benh nhan co bieu hien cua giang mai than kinh, neu thay phan ilng

am tinh trong DNT co the coi nhii da qua diidc thdi ky viem trong he than kinh va nhii vay cac tien trien khac cua benh

c h ic se khong xay ra nuta Trong cac triidng hdp tuy thay cac trieu chiing giang mai than kinh tien trien nhiing DNT lai hoan toan am tinh, kiem tra giai phau benh ly sau khi til vong thiidng chi phat hien diidc mot benh than kinh khong phai giang mai Khi dieu tri da lam cho DNT trd ve binh thiidng (dac biet la doi vdi te bao va protein) thi cac trieu chiing lam sang se ngiing tien trien; ngifdc lai neu thay te bao va protein tang len thi do la bieu hien bao triidc hoac kem theo sii tai phat cac dau hieu tren lam sang

4 Vdi giang mai bam sinh

Cac hoi chiing lam sang va cac phan ilng benh ly cung deu giong nhii trong cac the mac phai, duy nhat chi khac ve liia tuoi phat benh thoi Tat ca nhiing dac diem sinh hoc neu tren deu ilng dung diidc doi vdi giang mai bam sinh va mac phai

II CAC THE GIANG MAI THAN KINH CHINH

1 Giang mai than kinh km (khong co trieu chiing r5)

The nay thudng khong thay co dau hieu thiic the hoac trieu chiing ro ret; tuy vay trong mot so triidng hdp dong tii bat thiidng (vi du co dau hieu Argyll - Robertson) chan doan

hoan toan phai diia tren ket qua cua DNT; neu khong co trieu chiing cua DNT, chi co the coi la giang mai kin (d p h in 1 da neu ra cac bat thiidng cua DNT) Neu kiem tra giai phau benh thiidng chi thay te bao viem xam nhap vao mang nuoi, viem mang ong noi tuy 6i hat thiia va xam nhap nhe vao cac mach mau nao.

2 Giang mai m -ng nao

Sau khi mac giang mai, cac trieu chiing cua thiidng ton mang nao co the xay ra bat ky luc nao nhiing thiidng la trong vong hai nam dau Cac trieu chiing pho bien nhat gom nhiic dau, ciing gay, liet day than kinh so, cdn co giat va tam than lu lan Dot xuat, do ap liic qua cao trong so co the bi nhiic dau, phu gai thi, 1dm giong va non Khac v6i viem nang nao lao, benh nhan khong sot, DNT bao gid cung bat thiidng nhieu hdn

so vdi giang mai than kinh kin, vi trong the nay mang nao bi viem miic do nang hdn va con co the ket hdp them v6i tran dich nao Neu diidc dieu tri dung, tien liidng tot thi cac trieu chiing se thoai bien trong vong tCf vai ngay den vai tuan, nhiing neu thay DNT v in con bat thiidng thi phai canh giac vi cac the giang mai than kinh khac co kha nang con phat trien tiep theo

3 Giang mai mach mau mang nao

The giang mai than kinh nay hay xay ra d ngiidi tre tuoi diidi dang tai bien mach mau nao: co the thay dien ra dot ngot mot hoac nhieu lan tinh trang liet mia ngiidi, that ngon, mat cam giac, roi loan thi giac hoac tinh than lu lan Giang mai mach mau mang nao thiidng xuat hien vao khoang 6 - 7 nam sau nhiem khuan ban dau, nhiing cung co khi s6m hdn vao luc

6 thang hoac muon hdn sau 10 - 12 nam Trong DNT bao gid cung thay tang te bao, protein, gamaglobulin va phan iing huyet thanh diidng tinh Ve giai phau benh, ngoai sii xam

nhap vao mang nao con co hien ttfdng viem cac dong mach va phat trien xd hoa dan tdi hep long mach va sau cung gay tac mach Thudng ton mach mau do diidc goi la viem dong mach Heubner Ngoai ra trong mot so" trUdng hdp con thay ca viem mang nao - nao.

Cac dau hieu than kinh neu keo dai q ’ 6 'han g se ton liiu mai, nhiing dieu tri dung dan se ngan ngua cac giai doan dot quy sau nay Doi vdi cac triidng hdp da diidc dieu tri thich dang ma van thay tai bien mach mau nao tai dien, cam tim them cac nguyen nhan khac khong phai giang mai

4 Liet toan the

Liet toan the la benh viem nao - mang nao lan toa keo dai thiidng xay ra sau nhiem giang mai ban dau tii 15 den 20 nam The giang mai nao nay co dac diem la cac chtic nang tam tri bi suy thoai tien trien dong thdi phoi hdp vdi mot hoi chting liet nhe toan bo; neu khong diidc dieu tri sdm va tich ciic benh se dan den trang thai tam than sa sut, cd the suy mon va tti vong

4.1 LUGc SIS

Lich sti cua benh gan lien vdi cac biidc phat trien cua than kinh va tam than hoc Nam 1798, Haslam va Esquirol de cap triidc tien tdi nhting dac diem lam sang Nam 1822, Bayle da chinh thtic mo ta tach biet can benh nao coi nhii do mot nguyen nhan duy nhat la viem mang nhen man tinh Tiep do, Calmeil, Nissl va Alzheimer da bo sung them cac bieu hien giai phau benh ly Nam 1853, Lasegue de ra thuat ngti liet toan the tien trien va cung nhii mot so" tac gia khac, da kha nghi nguyen nhan benh nay do giang mai Sau khi Schaudinn

va Hoffmann phat hien ra xoan khuan, nam 1913 Noguchi cong tac vdi Moore da tim thay xoan khuan giang mai trong nao cac benh nhan liet toan the va nhii vay da chting minh diidc nguyen nhan giang mai cua benh nay Nam 1917 Wagner

Von Jauregg de ra phiidng phap dieu tri bang cach gav sot ret cdn Sau do Sezary va Barbe noi tdi hieu qua cua Stovarsol Nam 1943, Mahoney iing dung penicillin vao dieu tri da lam thay doi tien liidng cua benh nay.

4.2 Nguyen nhan

Nhan to" quyet dinh la xoan khuan giang mai Treponema Pallidum Thiidng ton la mot viem nao va mang nao toan bo, dac biet vo nao Cac bien doi giai phau thuoc loai viem, thoai hoa thay ro d mang nao, to chiic lien ket huyet quan, te bao than kinh va to chifc than kinh dem Ve dai the, mang nao viem day len xung huyet hoac co mau trang due nhat la d vung day, trong liidng toan bo nao giam, cac nao that ben gian vi nao bi teo Vi the thay te bao thap bi xam pham nhieu nhat Dien bien cua cac thiidng ton thiidng theo trinh tii nhii sau: te bao bi siing phu, cac hat Nissl bien dan roi den nhan te bao, tdi mot giai doan nao dd thi so" liidng te bao se bi giam, nhiing chu yeu la hien tUdng viem quanh huyet quan Vi tri cua thiidng ton rai rac lan toa d nao, nhan xam, tieu nao, tuy, mang nao v.v Ngoai ra con thay sii cd mat cua xoan khuan va sac to" sat trong vo nao va chat trang

- N han to" san co: nam gidi thudng m&c nhieu hdn nut gidi, gia dinh cd giang m ai di truyen va ban than nghien riidu cung nhif van de nghe nghiep va chung toe deu can dUdc chu y.

N han to" thuan ldi cd nhieu nhUng chi xin neu mot vai diem, dd la cd benh giang mai nhiing khong dieu tri hoac dieu tri muon, hoac dieu tri khong du va khong dung lieu trinh.

- Nhan to" khdi benh: thdi gian u benh rat lau, sau vet loet ban dau ben ngoai tii 4 den 10 nam sau mdi vao than kinh; thdi gian u benh thiidng ngiidc chieu vdi tuoi m ic benh, cang mac benh tre bao nhieu thi cang u benh lau bay nhieu Cung can neu ra ca nhan to" dot khdi: vi du nhif dang u benh

nhung bi met moi ve cd the hoac xuc dong tinh than qua nhieu nen benh bat chdt bung ra (tUdng nhu trdi quang vang sam nhUng ky thiic benh da u tii lau).

4.3 Lam sang

Giai doan triidc lam sang la giai doan huyet thanh vdi cac dac diem: trong DNT te bao tang v ia , protein tang khong qua 60mg/100ml, phan iing giang mai thiidng diidng tinh C) thdi ky nay benh nhan thudng hay cd nhiic dau dai dang

Giai doan khdi dau (thdi ky trudc liet) cd the theo hai cach: dot ngot, benh bat chdt bung len vai ngay vao ngay giai doan toan phat; hoac tiem tien, vi du d ngUdi nghien rUdu benh dan dan mdi ngay mot ro Cd the bat dau b&ng trieu chiing than kinh (tai bien than kinh) hoac trang thai tam than hoac

ca hai loai trieu chiing Day la nhiing trieu chiing cua thdi ky toan phat nhUng nhe hdn Bang dudi day cho thay cac the benh cd the gap trong giai doan khdi dau

Tai bien

than kinh

- The dot quy, trung phong

- Dong kinh

- Liet day than kinh so III, IV

- The than kinh suy nhUdc (nhifc dau, moi met, gay sut)

- The noi kho

- The roi loan tam than

- The sa sut tri tue

- The suy doi dao dUc (thdi ky phap y tam than)

Nghien ctiu tren 33 benh nhan liet toan the, chung toi thay 84,8% phai vao vien vi roi loan tam than vdi cac hanh dong pham phap va nhat la cac trang thai kich dong; so' cdn lai vao vien vi cac tai bien than kinh.

Giai doan toan phat (thdi ky liet): cd ba hoi chting ro ret la than kinh, tam than, the dich

+ Hoi chting than kinh: trong cac trieu chting cua giang mai than kinh cd dien, nhan manh tdi dau hieu Argyll- Robertson va cac roi loan sinh due, cd tron Trong cac trieu chting rieng cua liet toan the cd the thay: ve mat benh nhan thd than, dong tac rat it, khong cd bieu hien gi, cd nhting dong tac bat thifdng nhif giat sdi cd quanh mieng, giat cd quanh mat, giat ca mot nhom cd cung mot cd nang cho nen benh nhan cd khi nhai nhai nghien nghien; dac biet nhat la hien tUdng lifdi thap thd (dau hieu dong tac ken trombone cua Magnan) Chi tren run ray, chi difdi run thd hdn khien benh nhan dting lay bay khong vting Ve ngon ngti cd cac bieu hien noi kho va viet kho

+ Hoi chting tam than: cd sif pho'i hdp cua hai hoi chting

sa sut va hoang tifdng nen cd anh hifdng ldn den hanh vi Dac diem cua hoi chting sa sut la phai cd, sdm cd, toan bo va tien trien Ve mat tri tue, cac chtic nang chu yeu cd ban nhif chu y, tri nhd, phan doan deu suy thoai; cac chtic nang tong hdp nhif trifu tifdng, tong quat, suy luan, ngon ngti deu yeu kem Ve mat tinh cam, benh nhan khong kiem che difdc khi s ic nen hoac bieu lo hifng cam hoac tram cam cao do va cung vi tam than sa sut ma ban nang cung xuat hien mot cach au tri, thd

lo Dac diem cua hoi chting hoang tifdng la cac y tifdng lech lac nay sinh trong trang thai sa sut vdi noi dung phi ly nifc cifdi va luon luon thay doi Trong cac loai hoang tifdng, khuynh hifdng til dai kha pho bien (the khuech trifdng) Vi du, trong so cac benh nhan cua chung tdi, cd ngifdi til xifng la Tong thong Roosevelt, la Hoang tti xti Galles, la Nti hoang Elizabeth, la Bo

triidng Bo Ciiu te, la Pho Chu tich Trung Quoc, la Dai than, Dai tiidng, ThUdng sii.v.v Cac the khac cung khong hiem, vi

du vdi y tiidng nghi benh, tram cam, hoac hoang tiidng co ao giac Do tinh trang sa sut tri tue va co hoang tiidng nen cac benh nhan liet toan the hay co nhiing hanh dong gay ro'i loan trat til an ninh cua xa hoi, vi du trong the khuech triidng co the thay cac hien tiidng phi ly, phi phap hoac pho trufdng

tr in g trdn nhii lifa dao, danh nhau, gian dam hoac til sat, giet ngifdi

+ Hoi chiing the dich: trong mau phan iing huyet thanh thildng difdng tinh tdi 90%; 10% co the khong ro ret hoac am tmh Trong DNT, te bao lympho tang til 10 den 200 cai, te bao huyet tUdng va cac te bao mot nhan khac; protein toan phan tang tif 40 den 200mg trong 100ml; gamaglobulin cung tang va phan iing huyet thanh diidng tinh manh Co the thay xoan khuan trong DNT

4.4 The lam sang

The trieu chiing:

+ Cac the tam than bao gom: the sa sut ddn th u in , the

sa sut khuech trifdng, the tram cam, the nghi benh, the hoang tifdng ao giac.

+ Cac the than kinh bao gom: the tuy vi du liet toan the tabet, hoi chiing Guillain-Thaon (tabet ket hdp vcii liet toan the va liet hai chan); the nao vi du the dot quy, the dong kinh, the Lissauer (co trieu chiing khu tru viing thai difdng nhu that ngon, liet nhe niia ngifdi xuat hien sau mot dot quy, dong kinh); the tieu nao, hanh tuy, hat nhan xam trung ifdng

Ngoai ra con co nhiing the phoi hdp v6i nhiing bieu hien giang mai ngoai he than kinh hoac vdi nhiing benh khac nhu lao, nghien rifdu

- The tien trien:

+ The thong thtfdng tif luc dot khcli den trang thai bac nhifdc suy doi ciic do ca ve than kinh lin tam than trong vong

- The dia trang:

+ The cua nam gidi trung nien, dien hinh la the khuech trifdng vdi y ttfdng tu dai

+ The cua phu nut thifdng la tram cam

+ Ngoai ra con co the d ngifdi gia va the thanh thieu nien

4.5 Chan doan

- Chan doan quyet dinh difa vao sif phoi hdp cac trieu chifng than kinh va tam than nhif da mo ta tren va ket qua cua cac xet nghiem

- Trong chan doan phan biet:

+ Ve than kinh can phan biet cac trang thai dot quy, dong kinh do cac nguyen nhan khac nhif tai bien mach mau nao, u nao, viem nao.v.v ;

+ Ve tam than can phan biet vdi cac trang thai than kinh suy nhifdc, hiing - tram cam, sa sut, hoang tifdng va phap y tam than khac